Apparatus and method for heartbeat classification based on time sequence and morphology of intracardiac and body surface electrocardiogram (ECG) signals

ABSTRACT

Classification of heartbeats based on intracardiac and body surface electrocardiogram (ECG) signals are provided. Intracardiac ECG (IC-ECG) signals and body surface ECG (BS-ECG) signals are processed to perform heartbeat classifications. A BS annotation of BS-ECG signals reflective of a sensed heartbeat is defined, the BS annotation including a BS annotation time value. IC annotations of IC-ECG signals which reflect atrial-activity or ventricular activity of the sensed heartbeat are also defined, each IC annotation including an IC annotation time value. The IC-ECG signals are discriminated as A-activity or V-activity and IC annotations are designated as IC-A annotations or IC-V annotations, respectively. A respective A/V time sequence comparison of IC annotations reflective of the sensed heartbeat is made with one or more time sequence templates for heartbeat classification. Morphology comparisons of the BS-ECG oscillating signal segments reflective of the sensed heartbeat morphology templates for classification may also be made.

CROSS REFERENCE TO RELATED APPLICATION

The present application is a non-provisional of Provisional ApplicationNo. 62/619,242 filed Jan. 19, 2018 which is incorporated herein byreference as if fully set forth.

SUMMARY

Medical apparatus and methods configured to classify heartbeats based onintracardiac and body surface electrocardiogram (ECG) signals areprovided. An intracardiac catheter obtains multiple channels ofintracardiac ECG (IC-ECG) signals via respective multiple electrodeswhen disposed within a heart within a body of a subject. A body surfaceECG sensing device obtains multiple channels of body surface ECG(BS-ECG) signals via multiple electrodes when disposed on the body ofthe subject. A processor receives respective ECG signals from theintracardiac catheter and body surface ECG sensing device and processesthe signals reflective of sensed heartbeats to perform heartbeatclassifications.

An example apparatus includes a processor that defines a BS annotationof BS-ECG oscillating signal segments reflective of a sensed heartbeatof the subject, the BS annotation including a BS annotation time valuerelative to the sensed heartbeat. The processor performs a morphologycomparison of the BS-ECG oscillating signal segments reflective of thesensed heartbeat with one or more morphology templates, where eachmorphology template is associated with a heartbeat classification. Thesensed heartbeat is classified as corresponding to the associatedheartbeat classification of a template for which the morphologycomparison reflects a predetermined degree of morphology similarity.

The processor also defines IC annotations of IC-ECG oscillating signalsegments for each channel which reflect atrial-activity (A-activity) orventricular activity (V-activity) of the sensed heartbeat of thesubject, each IC annotation including an IC annotation time valuerelative to the sensed heartbeat. The processor discriminates IC-ECGoscillating signal segments as A-activity or V-activity and designatesIC annotations as IC-A annotations or IC-V annotations, respectively.The processor may then perform an Atrial time sequence comparison ofIC-A annotations reflective of the sensed heartbeat with one or moreAtrial time sequence templates, where each Atrial time sequence templateis associated with an A-activity classification, and classify the sensedheartbeat as corresponding to the associated A-activity classificationof a template for which the Atrial time sequence comparison reflects apredetermined degree of Atrial time sequence similarity. Alternatively,or in addition to, the processor may perform a Ventricular time sequencecomparison of IC-V annotations reflective of the sensed heartbeat withone or more Ventricular time sequence templates, where each Ventriculartime sequence template is associated with a V-activity classification,and classify the sensed heartbeat as corresponding to the associatedV-activity classification of a template for which the Ventricular timesequence comparison reflects a predetermined degree of Ventricular timesequence similarity.

The medical apparatus preferably includes an output device coupled tothe processor selectively output classifications of sensed heartbeatsresulting from morphology and time sequence comparisons. The processorcan also be configured to create a new morphology, Atrial time sequenceor Ventricular time sequence template based upon a condition that aheartbeat classification is not made based on a respective comparison toexisting morphology, Atrial time sequence or Ventricular time sequencetemplates.

In one example, the processor discriminates IC-ECG signal oscillatingsignal segments as A-activity or V-activity such that an IC-ECGoscillating signal segment is designated as V-activity upon a conditionthat the IC annotation time value relative to the sensed heartbeat iswithin a range of time values starting a predetermined amount before theBS annotation time value relative to the sensed heartbeat and ending apredetermined amount after the BS annotation time value relative to thesensed heartbeat and to otherwise designate the IC-ECG oscillatingsignal segment as A-activity. In such example, the processor maydesignate the IC-ECG oscillating signal segment as V-activity upon thecondition that the IC annotation time value relative to the sensedheartbeat is within a range of time values starting at no less than 20milliseconds before the BS annotation time value relative to the sensedheartbeat and ending no more than 80 milliseconds after the BSannotation time value relative to the sensed heartbeat.

In another example, the processor discriminates IC-ECG oscillatingsignal segments as A-activity or V-activity such that an IC-ECGoscillating signal segment is designated as A-activity or V-activitybased upon morphology characteristics of the IC-ECG oscillating signalsegment. In such example, the processor may discriminate IC-ECGoscillating signal segments as A-activity or V-activity such that anIC-ECG oscillating signal segment is designated as V-activity upon acondition that a combination of a slope and a width of a primaryoscillation is less than a predetermined threshold and to otherwisedesignate the IC-ECG oscillating signal segment as A-activity.

In a further example, the processor is configured to designate theIC-ECG oscillating signal segments as A-activity upon the condition thatatrial flutter is detected for the sensed heartbeat and a blankingwindow exists between successive IC-ECG oscillating signal segments forthe sensed heartbeat.

An example processor may be configured to perform an Atrial timesequence comparison of IC-A annotations reflective of the sensedheartbeat with an Atrial time sequence template by calculating a timevalue difference between the IC annotation time value of the IC-Aannotation for each channel of the sensed heartbeat and a respectivetemplate channel annotation time value and then determining that thepredetermined degree of Atrial time sequence similarity occurs when thecombination of the absolute value of the combined differences is nogreater than a selected A-time threshold. Such an example processor canalso be configured to perform a Ventricular time sequence comparison ofIC-V annotations reflective of the sensed heartbeat with a Ventriculartime sequence template by calculating a time value difference betweenthe IC annotation time value of the IC-V annotation for each channel ofthe sensed heartbeat and a respective template channel annotation timevalue and then determining that the predetermined degree of Ventriculartime sequence similarity occurs when the combination of the absolutevalue of the combined differences is no greater than a selected V-timethreshold.

The apparatus may employ a monitor as an output device that isconfigured to selectively display ECG signal and heartbeatclassification data of sensed heartbeats.

BRIEF DESCRIPTION OF THE DRAWINGS

A more detailed understanding can be had from the following description,given by way of example in conjunction with the accompanying drawings.

FIG. 1A is a schematic illustration of an electrocardiogram (ECG)analysis system, according to an embodiment of the present invention.

FIG. 1B is an example configuration of processing components of the bysystem shown in FIG. 1.

FIG. 2 is an example illustration of a catheterized heart organ.

FIG. 3A is a flow diagram of a method to identify and classify variousheart activations using morphology template comparison.

FIG. 3B is a flow diagram of a method to identify and classify variousheart activations that includes time sequence comparison in accordancewith the teachings of the present invention.

FIG. 3C is an example ECG time sequence comparison displaying goodsimilarity.

FIG. 3D is an example ECG time sequence comparison displaying poorsimilarity.

FIG. 4 is a graphic illustration of ECG signals of sensed heartbeatswhere a representative body source (BS) trace from BS electrodes isoverlaid on an intracardiac (IC) trace from an IC electrode of the samesensed heartbeats with annotation references noted.

FIG. 5 is a graphic illustration of ECG signals of a sample “normal”sensed heartbeat comparing body source (BS) traces from BS electrodes toan intracardiac (IC) trace from an IC electrode of the same sensedheartbeat with annotation references noted.

FIG. 6 is an expanded flow diagram of the time based example of the A-Vdiscrimination step FIG. 3B.

FIG. 7 is a graphic illustration of an ECG oscillating signal segmentusable as the basis of a morphology based example of A-V discriminationstep FIG. 3B.

FIG. 8 is a graphic illustration of clusters of A-activity andV-activity using the morphology example of A-V discrimination step FIG.3B.

FIG. 9 is a flow diagram of the morphology based example of A-Vdiscrimination step FIG. 3B.

FIG. 10 is a flow diagram of an atrial flutter (AFL) mode method in anembodiment of the present invention;

FIG. 11 is an expanded flow diagram of a portion of the AFL mode methodof FIG. 10.

FIGS. 12A-D is a comparison of the results of classification methods;FIG. 12A being a legend, FIG. 12B a body scan (BS) graph, FIG. 12C anInfraCardiac (IC) graph without AFL mode method and FIG. 12D an IC graphwith AFL mode method.

DETAILED DESCRIPTION

The normal sinus rhythm of heartbeats commences when the sinoatrial (SA)node in the heart initiates a depolarization wave over the atrial tissueresulting in atrial heart muscle contraction, pushing blood in the atriainto the ventricles. After a delay of about 70 ms, a depolarization waveinitiating in the atrioventricular (AV) node passes over the ventricularheart tissue resulting in a ventricular muscle contraction that pushesblood out of the ventricles. Preparation or “reset” for the nextheartbeat occurs with repolarization waves in both the atria andventricles. This electrical activity results in the classic ECG waveformmorphology (e.g., P-wave, QRS-complex, T-wave) that can be detectedusing ECG body surface (BS) electrodes. Each heart beat is reflected asan oscillating segment in the BS-ECG signal.

The atrial and ventricular activation waves, produced by the SA node andpassed through AV node, spread out over the heart muscle as a wave frontwith a spatially dependent propagation time. When using Intra-Cardiacelectrodes to generate an ECG, i.e. IC-ECG, the IC-ECG signal includesoscillating segments reflecting respective atrial and ventricularactivity of a heartbeat. For a normal heart beat, an atrial oscillatingsignal segment will be separate from and precede (in time) a ventricularoscillating signal segment. However, in some types of abnormal heartbeats, oscillating signal segments reflecting atrial and ventricularoscillating signal segments will overlap in time.

Unstable heart activation causes the wave activation inside a heartchamber to change between heartbeats. Because activation activities maynot always be constant, the likelihood that particular relevantactivities will be missed by the physician is significant. Cardiacmapping, for example, creating a map of electrical potentials (a voltagemap) of the wave propagation along the heart tissue or a map of arrivaltimes (a local time activation (LAT) map) to various tissue locatedpoints may be used for detecting local heart tissue dysfunction

Annotation of the ECG oscillating signal segments may be used toindicate a consistent timing in the heart cycle in order to create areliable LAT map. Annotations refer to points of time on an electrogramthat are considered to denote events of interest. A misclassifiedannotation can cause acquisition of false volume and false localactivation timing into the map. The common practice is to place thereference catheter in a stable position in the coronary sinus (CS).Recording of the catheter's ECG at that position records both atrial andventricular contractions which represent different timings of the heartcycle; because of the different timings, it is important todifferentiate the atrial and ventricular contractions. The suggestedmethods presented herein assure A-V differentiation thus providing areliable and consistent reference.

To assist the physician in finding relevant activities, an enhancedsystem to track and understand the different activation activities thatoccur during the mapping process is needed.

The present system provides enhanced understanding of unstable heartactivation by focusing on the sequence of activity inside a catheterplaced within some stable position (for example, a “CS catheter” placedwithin the coronary sinus (CS)). This information may be used tounderstand the source of the normal and/or abnormal heart activation.

CARTO™ electroanatomic mapping and navigation system produced byBiosense Webster, Inc. (Diamond Bar, Calif.) uses a mapping catheterwith a localization sensor in its tip to automatically andsimultaneously acquire an electrogram and determine itsthree-dimensional coordinates.

A method of position sensing is implemented in the above-mentionedCARTO™ system and is described in detail in U.S. Pat. Nos. 5,391,199,6,690,963, 6,484,118, 6,239,724, 6,618,612 and 6,332,089, in PCT PatentPublication WO 96/05768, and in U.S. Patent Application Publications2002/0065455 A1, 2003/0120150 A1 and 2004/0068178 A1, whose disclosuresare all incorporated herein by reference.

The CARTO™ system also implements a method for cardiac mapping basedupon determination and analysis of ECG signal annotations, which isdescribed in detail in U.S. Pat. Nos. 8,700,136 and 9,259,165, whosedisclosures are both incorporated herein by reference.

FIG. 1A is a schematic overview of the medical apparatus 1 in accordancewith an example embodiment of the present invention. As shown in FIG.1A, the medical apparatus 1 is configured inter alia to classify sensedbeats of a heart 21 of a subject or patient 22 and includes one or moremedical tools (e.g., mapping catheters, reference catheters, ablationcatheters, etc.), such as intracardiac catheter 10, and a work station12 having a processor 14, an associated display or monitor 16, acatheter hub 18, a location pad (LP) driver 20, Wi-Fi antenna 24, RFSync Tx antenna 26 and RF Sync Rx antenna 28. The LP driver is coupledto a location pad (not shown) disposed beneath the patient 22. Theintracardiac catheter 10 has an array of catheter sensors (e.g.,electrodes) 11 at a distal end 17. Each sensor is configured to detectelectrical activity (electrical signals) of an area of the heart 21 overtime. In one embodiment, each electrode 11 is a metal ring on thesurface of the intracardiac catheter 10. When an intracardiacelectro-cardiogram (IC ECG) is performed, each electrode 11 detects theelectrical activity of an area of the heart 21 with which it is incontact.

In one embodiment, the processor 14, e.g., a hardware unit (“PIU”), isconfigured to process the signals received from the sensors 11 tocalculate ECG values with respect to the catheter tip. The processor 14may be specialized processing hardware. The received data, e.g., ECGsignals from the intracardiac catheter 10, may be processed by areference annotation method, as discussed below. The processor 14includes memory resources for organizing the received data.

The catheter hub 18 is configured to receive data from multiple sensors,which may include the sensors 11, for navigation. The LP driver 20drives current, such as AC, to the location pad to enable fieldgenerators within the pad to generate magnetic fields which define areference magnetic field for navigation of the catheter 10. The catheterhub 18 may be hard wired or include a Wi-Fi antenna 24 and an RF Sync Rxantenna 28, for receiving signals from the tools that are navigated. TheLP driver 20 may be hard wired or include a Wi-Fi antenna 24 and an RFSync Tx antenna 26 enabling the LP driver 20 to transmit current to thelocation pad.

The position and orientation of the distal end of the intracardiaccatheter 10 may be ascertained by determining the position of a magneticfield locating sensor within its distal end 17. The intracardiaccatheter 10 may be locatable with a non-ionizing field, such as anelectromagnetic or acoustic field. The distal end 17 of the intracardiaccatheter 10 may comprise a transmitting or receiving antenna (not shown)for the relevant field. Receiving or transmitting antennas for thenon-ionizing field may be attached to the patient 22 for aidingnavigation. A receiver or transmitter is connected to these antennas,and converts the received field waves into electrical locating or imagesignals.

The location pad may comprise coils (not shown), which are one type ofmagnetic transducer that may be used in embodiments of the presentinvention (see incorporated U.S. Pat. No. 6,618,612). A “magnetictransducer,” in the context of the present patent application and in theclaims, means a device that generates a magnetic field in response to anapplied electrical current and/or outputs an electrical signal inresponse to an applied magnetic field.

The work station 12 can be detachably connected via an output connectionto the display 16. The work station 12 is also detachably connected viaan input connection to the catheter hub 18 to which one or more medicaltools can be connected. The input and output connections may behard-wired or Wi-Fi connections, or both. One or more tools, such as theintracardiac catheter 10, may be navigated through the patient's heart21. Although the work station 12, the LP driver 20 and the catheter hub18 are shown included together as a single component, they may all beseparate components, or variously combined as fewer components.

In use, the intracardiac catheter 10 may be percutaneously inserted intothe body of the subject 22 during a cardiac mapping procedure performedby a user 8. In the description herein the user 8 is assumed, by way ofexample, to be a physician or other medical professional. Body surfaceelectrodes 13 of a body surface ECG sensing device 30 may be attached tothe skin of subject 22. During a procedure, the subject 22 is preferablyattached to a grounding electrode 23.

For simplicity and clarity, the following description, except whereotherwise stated, assumes a medical procedure that senses electricalsignals from the heart 21, using electrodes 11 disposed on theintracardiac catheter 10 and the electrodes 13 of the body surface ECGsensing device 30. As illustrated in FIG. 1B, the electrodes can becoupled to an ECG signal interface 42 which inputs the sensed electricalsignals into the processor 14.

When the electrodes 11 contact the heart tissue and the electrodes 13contact the subject's body, the processor 14 receives multipleelectrical signals from the electrodes. For heartbeat classification,the intracardiac catheter 10 is positioned in a reference region of theheart, such as in the coronary sinus, and used to sense intracardiac(IC) ECG signals from the region while the electrodes 13 are used tosense body surface (BS) ECG signals.

The processor 14 is typically mounted in a console 12, which comprisesoperating controls 15. The controls 15 typically include a pointingdevice, such as a mouse or a trackball. A professional 8 can use thepointing device to interact with the processor 14. Results of theoperations performed by processor 14 are presented to the user 8 on adisplay 16, which typically presents a graphic user interface to theoperator, a visual representation of the ECG signals sensed by theelectrodes 11 and 13.

FIG. 1B is an example configuration of the processor 14 which may be ageneral purpose processor configured with software or a specialprocessor such as an application-specific integrated circuit (ASIC). Theprocessor can be configured with a probe navigation module 35 and an ECGmodule 36, to respectively control the positioning of the intracardiaccatheter 10 and the processing of the ECG signals. The ECG module 36 caninclude a reference ECG sub-module 37 and a map ECG sub-module 41, whosefunctions are described below. Software may be downloaded to theprocessor 14 in electronic form, over a network, for example, or it may,alternatively or additionally, be provided and/or stored onnon-transitory tangible media, such as magnetic, optical, or electronicmemory. The ECG signal interface 42 receives the ECG signals fromIntracardiac (IC) electrodes 11 and the Body Surface (BS) electrodes andrelays the signals to processor 14. ECG module 36 is configured toanalyze the received ECG signals and may present the results of theanalysis in a standard ECG format, typically a graphical representationmoving with time, on display 16. For navigation, the signals from theIntracardiac (IC) electrodes 11 may be used as references with respectto signals from sensors of additional catheters as described in the U.S.Patents referenced above.

The probe navigation module 35 tracks sections of catheter 10 withinsubject 22. The navigation module typically tracks both the location andorientation of the distal end of the catheter 10 within the heart 21 ofthe subject 22. In some embodiments module 35 tracks other sections ofthe catheter or other tool. The navigation module 35 may use any methodfor tracking tools known in the art. For example, the navigation module35 may operate magnetic field generators in the vicinity of the subject,so that magnetic fields from the field generators interact with trackingcoils located in sections of the probe being tracked. The coilsinteracting with the magnetic fields generate signals which aretransmitted to module 35, which analyzes the signals to determine alocation and orientation of the coils. For simplicity such coils andfield generators are not shown in FIG. 1A. The Carto® system produced byBiosense Webster, of Diamond Bar, Calif., uses such a tracking method.

Alternatively or additionally, the navigation module 35 may track thecatheter 10 by measuring impedances between the ground electrode 23, thebody surface (BS) electrodes 13 and the IC electrodes 11, as well as theimpedances to other electrodes which may be located on the probe. The ICelectrodes 11 and/or BS electrodes 13 may provide both ECG and trackingsignals. The Carto3® system produced by Biosense Webster uses bothmagnetic field generators and impedance measurements for tracking.

FIG. 2 illustrates the example subject's heart 21 which includes aCoronary Sinus (CS) 201. The CS 201 separates the left atrium 202 fromthe left ventricle 203. The IC catheter 10 direction may be projected onthe display 16 of the IC catheter 10 along with a time sequence. Heartactivity propagation that is projected on the IC catheter can be used togenerate a time sequence of ECG signal appearances in differentelectrodes. The directions can be from distal to proximal electrodes,from proximal to distal electrodes, or more complex patterns that mayinclude electrodes of multiple catheters. Determining the direction canprovide important information regarding source of the heart activation.

Decapolar catheters are typically used in the CS 201. For example, theIC catheter 10 may be a WEBSTER® Decapolar Deficable Catheter comprisingfive pairs of evenly spaced electrode sensors 11. Other examples includeWEBSTER® PentaRay® NAV or Navistar® Thermocool® catheters that may beused in addition to catheter 10 or as alternatives.

To visualize an activation wave on the heart 21, a reference point intime is needed, from beat to beat and for each anatomical position pointtaken during a mapping process. A physician can track time about thereference point. The coronary sinus provides an excellent referencepoint because it is positioned between the atrium and the ventricle,allowing the catheter 10 to closely monitor both atrial activity andventricular activity. However, other locations can be used.

The sensed heart activity is advantageously used for mapping thedifferent sections of the heart 21. When is mapping the atrium 202,atrial activity can be used as a reference. When mapping the ventricle203, ventricular activity can be used as a reference.

Further, the CS is an optimal reference point because the time patternsof the CS activations can be helpful in atrial tachycardia (AT) mapping.The analysis of time patterns of CS activation provides a rapidstratification, or ordering, of most likely macro-reentrant ATs (MRATs),and the analysis also points toward the likely origin of focal ATs.

During a medical procedure to examine a patient's heart, CARTO™ systemaccumulates information as the physician 8 (or other medicalpractitioner) moves the catheter 10 or other tool within the patient'sheart 21 from point to point and filters the data obtained from thecatheter 10 or other tool for “relevant” data. For example, CARTO™ cancalculate the time of a heartbeat cycle length, e.g., “beat-to-beattime”, and this information can be used for analyzing the patient'sheart behavior.

Enhanced understanding of heart activation requires more detailedinformation than provided by existing systems; for instance, filtersthat recognize activity and/or activation from more than one directioncan provide enhanced understanding of heart activation. To overcome thisdeficiency, techniques to determine CS catheter 10 direction can beemployed. Additionally, heartbeat classification may be employed toenhance mapping of the heart for use in further medical procedures.

FIG. 3A is a flow diagram of an improved method for preparingelectroanatomic maps of the heart adapted from commonly owned U.S.Patent Publication No. 2018/0008203, Automatic Creation of MultipleElectroanatomic Maps, which is incorporated by reference as if fully setforth, that include heartbeat classification using a morphologicalcomparison of ECG heartbeat signals. The process steps are shown in aparticular linear sequence. However, it will be evident that many ofthem can be performed in parallel, asynchronously, or in differentorders. Those skilled in the art will also appreciate that a processcould alternatively be represented as a number of interrelated states orevents, e.g., in a state diagram. Moreover, not all illustrated processsteps may be required to implement the method.

At an initial step 301 the heart is catheterized with the electrodes ofthe catheter preferably placed in galvanic contact with the CS. Next, atstep 302, intracardiac electrograms, i.e. sensed ECG signals, arerecorded and oscillating ECG signal segments reflective of heartactivity are annotated with the multiple electrodes of the catheter,each having a respective location, which can be determined using theposition tracking capabilities of the medical apparatus depicted in FIG.1.

The recordings may be obtained and processed concurrently. Theelectrograms may be recorded and data collected throughout acatheterization session as the catheter is navigated within the heart.Additionally or alternatively the data may be collected in a “huntingmode”, wherein the catheter is stable in a location, and the operatorawaits rhythm changes generally, or the appearance of a particulararrhythmia. The data may be collected using unipolar or bipolarelectrode configurations.

Annotation of the intracardiac electrograms defines respective timevalue annotations of oscillating ECG signal segments and may beperformed using the teachings of commonly assigned U.S. PatentPublication No. 20150073246, entitled Method for MappingVentricular/Atrial Premature Beats During Sinus Rhythm, U.S. Pat. No.9,380,953, entitled Hybrid Bipolar/Unipolar Detection of ActivationWavefront, and U.S. Patent Publication No. 20150208942, entitled DoubleBipolar Configuration for Atrial Fibrillation Annotation, which areherein incorporated by reference.

Next, heartbeat classification, step 303, using a morphologicalcomparison of the shape of oscillating ECG signal segments is performed.The morphology comparison of oscillating signal segments reflective ofthe sensed heartbeat is conducted with respect to one or more morphologytemplates, where each morphology template is associated with a heartbeatclassification. The sensed heartbeat is classified as corresponding tothe associated heartbeat classification of a template for which themorphology comparison reflects a predetermined degree of morphologysimilarity.

As explained in detail in U.S. Patent Publication No. 2018/0008203, suchmorphology comparison may comprise a template selection step 303A, atemplate matching step 303B, in which the morphology of the intracardiacelectrograms is automatically matched to the templates beat-by-beat, anda data accumulation step 303C. The templates are typically user defined,and may represent a pre-defined signal morphology based on an averageheartbeat waveform of the patient, and/or signal estimation for ananomaly such as a fibrillation. Additional new templates may also bederived from the morphology of oscillating ECG signal segments of asensed heartbeat when a heartbeat classification is not made based on arespective comparison to existing morphology, time sequence or combinedtemplate.

Following the classification and data accumulation, a functionalelectroanatomic map, e.g., an LAT map, is automatically generated, step304. A detailed explanation of steps 301-304 for LAT map generation isprovided in U.S. Patent Publication No. 2018/0008203.

Different information is reflected in the ECG signals sensed by the ICelectrodes 11 and the BS electrodes 13. FIG. 5 is a graphic illustrationof ECG signals of a typical normal sensed heartbeat comparing bodysource (BS) traces from BS electrodes 13 to an intracardiac (IC) tracefrom an IC electrode 11 of the same sensed heartbeat with annotationreferences noted. As illustrated in FIG. 5, traces 501 of BS-ECG signalseach characteristically reflect a single oscillating signal segment forthe sensed heartbeat. By comparison, the trace 503 of the IC-ECG signalcharacteristically reflects two oscillating signal segments for thesensed heartbeat; the first 505 corresponding to atrial activationactivity (IC-A segment) and the second 507 corresponding to ventricularactivation activity (IC-V segment).

Building upon the prior classification and mapping technique discussedabove with respect to steps 301-304, an additional step 305 ofatrial-ventricular differentiation of oscillating IC-ECG signal segmentscan be performed. Such differentiation may be made, for example, by atime sequence technique described with respect to FIGS. 4-6 below and/ora morphological technique described with respect to FIGS. 7-9 below.

In preparation of atrial-ventricular differentiation 305, in step 302,signals from each IC electrode are segmented and annotated to produce atime value annotation for each oscillating signal segment of each ICchannel, each electrode defining a separate IC channel. However, anannotation of the collective BS channel signals for a sensed heartbeatcan be advantageously employed in conducting the atrial-ventriculardifferentiation.

When atrial-ventricular differentiation 305 is employed in the methoddepicted in FIG. 3A, the IC-A signal segments and the IC-V signalsegments can be processed in separate groups with the morphologyclassification being performed separately with respect to the IC-Asignal segments and the IC-V signal segments. In such manner, theprocessed IC-A segments can be advantageously used in creating atrialmappings and the processed IC-V segments can be advantageously used increating ventricular mappings. For implementation in the medicalapparatus 1, typically the processor 14 is configured to perform steps301-305.

Although morphology classification works well with BS-ECG signalsegments, the inventors have recognized that heart beat classificationon a time sequence comparison can be advantageously employed forheartbeat classification of IC-ECG signal segments.

FIG. 3B is a flow diagram of a system of heartbeat classification of ECGsignal segments that employs both morphology and time sequencecomparisons. For implementation in the medical apparatus 1, typicallythe processor 14 is configured to perform the classification process.

For one example, in an initial step 306, a flag value can be set todefine the activity source of an oscillating signal segment of interest,i.e. atrial (“A”) or ventricular (“V”). The flag value is typically setby the user 8, but may be set automatically as part of a pre-configuredprogram. For example, the Flag may first be set to “A” to accumulatedata for an atrial mapping and the switched to “V” to reprocess the ECGsignals to accumulate data for a ventricular mapping.

In step 307, ECG signals are received from multiple electrodes, such asfrom both the Intracardiac (IC) electrodes 11 and the body surface (BS)electrodes 13. The oscillating signal segments are processed andannotated to define annotations that include a time value relative torespective sensed heartbeats as described above in connection with Step302 of FIG. 3A. Signals from each IC and BS electrode are segmented andannotated to produce a time value annotation for each oscillating signalsegment of each IC and BS channel, each electrode defining a separate ICor BS channel. However, an annotation of the collective BS channelsignals for a sensed heartbeat can be advantageously employed inconducting subsequent atrial-ventricular differentiation of the IC-ECGsignal segments.

In step 308, a determination is made as to whether the annotatedoscillating signal segment is from a BS-ECG signal originated from bodysurface (BS) electrodes 13 or not. If it is, the BS-ECG signal segmentdata is passed for collection and processing in a morphology comparisonstep 312. In step 312, the BS signal segments are analyzed to detectsimilarity or difference of a sensed heartbeat by morphology templatecomparison. This process can be conducted as explained above in step 303of the process illustrated by FIG. 3A.

The non-BS signal segment data, i.e. the IC-ECG oscillating signalsegment data, passes though the decision step 308 to anatrial-ventricular differentiation/discrimination step 309. Thediscrimination between A-activity versus V-activity can be made invarious ways as referenced with respect to step 305 of the processillustrated by FIG. 3A. Such differentiation may be made using IC-ECGoscillating signal segment annotations, for example, by a time sequencetechnique described with respect to FIGS. 4-6 below and/or by using theIC-ECG oscillating signal segment shape in a morphological techniquedescribed with respect to FIGS. 7-9 below. In connection with thediscrimination of the IC-ECG oscillating signal segments as A-activityor V-activity, the respective annotations of the IC-ECG segments aredesignated as IC-A annotations or IC-V annotations,

In step 310, the IC-ECG oscillating signal segments are filtered basedon the flag value set in step 306. Where the flag value is “A,” theIC-ECG oscillating signal segment data reflecting Atrial activity ispassed to step 311 for further processing, otherwise the IC-ECGoscillating signal segment data is returned to await processing when theflag value is set to “V.” Where the flag value is “V,” the IC-ECGoscillating signal segment data reflecting Ventricular activity ispassed to step 311 for further processing, otherwise the IC-ECGoscillating signal segment data is returned to await processing when theflag value is set to “A.”

In contrast to the morphology classification process of step 312 for theBS-ECG oscillating signal segment data, in step 311, the “A” or “V”IC-ECG oscillating signal segment data passed from the filtering step310, is processed using a time sequence classification process. In step311, the IC-A annotations (or IC-V annotations) for all of the IC-ECGchannels relative to a sensed heart beat are compared to one or morepre-determined templates. In lieu of selecting either “A” or “V” IC-ECGdata, annotations from both could be used in a comparison step againstan IC-A/IC-V combination template.

FIGS. 3C and 3D show schematic views of two time sequence comparisonswith the same template of IC-ECG oscillating signal segment data withrespect to two different sensed heartbeats per step 311 of FIG. 3B.

FIG. 3C is an example time sequence comparison graph 314 displaying goodsimilarity between template annotations (black points) 315 of templateECG channel traces 317 (dashed lines) and the annotations (white points)316 of the IC-ECG oscillating signal traces 318 (solid lines) of datawith respect to a first sensed heartbeat. A dotted trend line is shownconnecting the template annotations 315.

FIG. 3D is a second example time sequence comparison graph 324displaying bad similarity between the same template annotations (blackpoints) 325 of template ECG channel traces 329 (dashed lines) and theannotations (white points) 326 of the IC-ECG oscillating signal traces327 (solid lines) of data with respect to a second different sensedheartbeat. Here, the template annotations 325 and template ECG channeltraces 329 are identical to the template annotations 315 and templateECG channel traces 317 of FIG. 3C.

To determine similarity or dissimilarity of “A” IC-ECG oscillatingsignal segment data of a sensed heartbeat with the template annotationsof an Atrial time sequence template, the processor 14 can be configuredto perform an Atrial time sequence comparison of IC-A annotationsreflective of the sensed heartbeat with the Atrial template annotationsby calculating a time value difference between the IC annotation timevalue of the IC-A annotation for each channel of the sensed heartbeatand a respective template channel annotation time value. Thepredetermined degree of Atrial time sequence similarity can then bedetermined to occur when the combination of the absolute value of thecombined differences is no greater than a selected A-time threshold.

To determine similarity or dissimilarity of “V” IC-ECG oscillatingsignal segment data of a sensed heartbeat with the template annotationsof a Ventricular time sequence template, the processor 14 can beconfigured to perform a Ventricular time sequence comparison of IC-Vannotations reflective of the sensed heartbeat with the Ventriculartemplate annotations by calculating a time value difference between theIC annotation time value of the IC-V annotation for each channel of thesensed heartbeat and a respective template channel annotation timevalue. The predetermined degree of Ventricular time sequence similaritycan then be determined to occur when the combination of the absolutevalue of the combined differences is no greater than a selected A-timethreshold.

Alternative methods of determining similarity may be implemented thatinclude, but are not limited to, sum of absolute differences, route meansquares, weighted values of same or Minkowski distance comparison.

Initial Atrial time sequence and Ventricular time sequence templates canbe based on respective “A” and “V” IC-ECG oscillating signal segmentdata of a normal heartbeat or averages of a series of normal heartbeatsof the subject. New templates can be generated by the processor from “A”or “V” IC-ECG oscillating signal segment data based upon a conditionthat a heartbeat classification is not made based on a respectivecomparison to existing morphology, Atria time sequence or Ventricle timesequence templates for that data. For example, the annotations (whitepoints) 326 of the IC-ECG oscillating signal traces 327 (solid lines) ofdata with respect to the second different sensed heartbeat illustratedin FIG. 3D could be used as a basis of a new second template forcomparison to IC-ECG signals of subsequent sensed heartbeats.

FIGS. 4-6 illustrate a time sequence technique for A/V differentiationusing IC-ECG oscillating signal segment annotations. FIG. 4 is a graphicillustration of ECG signals of a series of four sensed heartbeats wherea representative body source (BS) trace 401 from BS electrodes 13 isoverlaid on an intracardiac (IC) trace 403 from an IC electrode 11 ofthe same series of sensed heartbeats. Annotations of the oscillatingsignal segments are illustrated. Note that a point representing anyspecific component of the reference ECG may be used as the referenceannotation. By none limiting way of example, such components can includemaximum (peak positive) deflection of heart beat, minimum (peaknegative) deflection of heart beat, maximum upslope (dV/dT), maximumdownslope and/or energy center of the complete heartbeat. The choice ofspecific point or some integrative position (such as energy center)depends on the method used to perform the analysis.

The time values of BS annotations (triangles) 405 of BS oscillatingsignal segments general fall between respective IC-A annotations(circles) 407 and IC-V annotations (squares) 409 of IC oscillatingsignal segments for a given sensed heartbeat. This results in a classictriangular relationship 410 of the BS, IC-A and IC-B annotations for agiven sensed heartbeat. These characteristics of normal hearty activityare explained in further detail in U.S. Pat. No. 9,259,165.

FIG. 5 further illustrates these characteristics for a single sensedheartbeat. As illustrated in FIG. 5, traces 501 of BS-ECG signals eachcharacteristically reflect a single oscillating signal segment for thesensed heartbeat. Separately presented is trace 503 of the one IC-ECGsignal channel that characteristically reflects two oscillating signalsegments for the sensed heartbeat; the first 505 corresponding to atrialactivation activity (IC-A segment) and the second 507 corresponding toventricular activation activity (IC-V segment). For illustrativepurposes, a collective BS annotation 511 is provided on the graph of theIC ECG trace along with the IC-A annotation 515 and IC-V annotation 507of the respective IC oscillating signal segments.

In order to determine whether a particular IC oscillating signal segmentrepresents atrial activation activity or ventricular activationactivity, a comparison of the time value of the annotation of the ICoscillating signal segment with the time value of the annotation of theBS signal segments for the sensed heartbeat. The inventors haverecognized the generally the IC-V type annotations are much closer intime value to the time values of respective BS annotations than are thetime values of IC-A type annotations. Although usually, a BS annotationoccurs before a respective IC-V annotation as described for example inU.S. Pat. No. 9,259,165, the inventors have recognized that this may notalways be the case. Accordingly, a time sequence A/V differentiationtechnique is provided based on a comparison of IC annotation time valuesto a range within which time values of respective BS annotations fall.

In implementation, to perform step 309 of FIG. 3B, the processor 14 isconfigured to discriminate IC-ECG signal oscillating signal segments asA-activity or V-activity such that an IC-ECG oscillating signal segmentis designated as V-activity upon a condition that the IC annotation timevalue relative to the sensed heartbeat is within a range of time valuesstarting a predetermined amount before the BS annotation time valuerelative to the sensed heartbeat and ending a predetermined amount afterthe BS annotation time value relative to the sensed heartbeat and tootherwise designate the IC-ECG oscillating signal segment as A-activity.Generally, for a IC-ECG signal oscillating signal segments to beclassified as V-activity, the IC annotation must between two limits“lim1” and “lim2” bracketing the BS annotation 511 as illustrated inFIG. 5. This is in fact the case for the illustrated IC annotation 517which is an IC-V annotation. If the IC annotation does not fill withinthe range defines by “lim1” and “lim2,” it is classified as directed toatrial activity by default. In one embodiment, the limit values are setalong the X-axis (time) at about 20 ms for lim1 and 80 ms for lim2.

FIG. 6 is an example flow diagram of this time sequence method ofdiscrimination between IC-A and IC-V activities based on BS annotations.As indicate in the flow diagram, the method computes the weightedaverage of the channel annotations (from an IC annotation bufferannoBuffIC) and compares the obtained value (appxGrpAnno) with BSannotations contained in a corresponding buffer (annoBuffBS). If thedifference appxGrpAnno-annoBuffBS falls within the boundaries, e.g.,{lim1,lim2} which can have default values of −20 ms, 80 ms, the methodcalculates the group annotation and reports the new IC annotation asIC_V type. To calculate the group annotation value, the method uses thelast previous classified IC_V annotation results. If the condition isnot met, the method checks an additional condition: are there anydetected BS annotations within the limits of the current IC segment? Ifthis condition is true, then the method calculates the group annotationand reports the new IC annotation as IC_V type. Otherwise as well asafter the IC_V annotation calculation, the method starts checking forIC_A activity presence.

The condition of IC_A activity presence is a set of rules that checksthe following:

Is given appxGrpAnno located before the current data buffer (too muchtime passed)?

Is given appxGrpAnno checked when a later IC_V activity has beenclassified before?

Is given appxGrpAnno older than last BS annotation (from annoBuffBS)?

If one of these conditions is true, the analyzed activity is classifiedas IC_A. The method calculates the group annotation and reports the newIC annotation as IC_A type. If none of the conditions is true, themethod proceeds to the next step.

The last step of the method is to clean up the BS annotation buffer, ifit contains expired BS annotations.

The method may use the inter activation time as a template that ismatched with any other heartbeat in the accumulated data. The method mayalso include processes to handle “miss of activation”, that is,activations that are missed or skipped in some of the channels as somesignals may become very small during the medical procedure, e.g., due tominimal patient respiration.

Accordingly, the present method can recognize the difference, e.g., candifferentiate, as heartbeat changes mode.

FIG. 6 shows the following steps:

Step 601: Obtain annoBuffIC and annoBuffBS.

Step 602: Calculate IC annotation and BS annotation, typically in realtime. The IC annotations may be calculated per channel. These calculatedannotations are stored in buffers, e.g., IC annotation buffer(annoBuffIC) and BS annotation buffer (annoBuffBS).

Step 603: Estimate appxGrpAnno by computing weighted average of ICchannel annotations using annoBuffIC.

Step 604: Determine whether lim1<appxGrpAnno<lim2. If appxGrpAnno isbetween lim1 and lim2 (604=YES), then Step 605, select the lastclassified IC_V channel annotations and estimate new IC group annotation(GrpAnno)

Step 606: report new annotation as IC_V and remove used IC/BSannotations from buffers.

Step 607: Determine whether there is additional IC_A activity. If thereis additional activity (607=YES), in step 608, select the lastclassified IC_A channel annotations and estimate new IC groupannotation.

Step 609: Report new annotation as IC_A and remove used IC/BSannotations from buffers. Continue at step 610.

If no additional activity is detected (607=NO), continue at step 610.

Step 610: Determine whether BS annotation is expired. If the BSannotation is expired (610=YES), at step 611, remove expired BSannotations from buffers. Continue at step 601.

If BS annotation is not expired (610=NO), continue at step 601.

If the apprxGrpAnno is not between lim1 and lim2 (604=NO), at step 612,then determine whether annoBuffBS is between segment(1) and segment(2)[segment(1)<=annoBuffBS<=segment(2)]. If annoBuffBS is between these twolimits, then go to step 605. If annoBuffBS is not between these twolimits, then go to step 607.

FIGS. 7-9 illustrate a morphological technique for A-V discriminationusing the IC-ECG oscillating signal segment morphological (shape)features. For implementation, processor 14 is configured to discriminateIC-ECG oscillating signal segments as A-activity or V-activity such thatan IC-ECG oscillating signal segment is designated as A-activity orV-activity based upon morphology characteristics of the IC-ECGoscillating signal segment.

In one embodiment, two characteristics may be used as morphologycharacteristics of the heartbeat. One characteristic is the slope(direction) of the line connecting “peak-to-peak” (MAX-MIN) points ofthe heartbeat. Another characteristic is the width of the heartbeat mainpeak at a certain level.

FIG. 7 illustrates direction and width parameter definitions formorphological features. Both the width 701 between main peaks at acertain level and the direction of the slope 702 are illustrated. Thedirection parameter 702 may be used as a morphological feature becauseA-activities and V-activities originate from different sources andtherefore have different arrival directions. The width parameter 701shows that the V-activity ECG relative to the A-activity ECG containsmore low-frequency components. Because it is reasonable to expect thatthe value of the width parameter 701 for the V-activity will be higherthan for the A-activity, the width parameter 701 is anothermorphological feature of interest.

FIG. 8 illustrates results of classifying A-activities and V-activitiesof the intracardiac ECG. As shown in FIG. 8, two point groups 801, 802are clearly separated in Direction-Width coordinates. The upper group801, which has a smaller spread of its members (in direction), isrelated to V-activity.

FIG. 9 is a flow diagram of the classification method based on themorphologic parameters. For a given activity interval (segment(i)), anormalization is performed for every channel of IC reference ECGs(ECG(k)). Then the method calculates the direction (direct(k)) and width(width(k)) parameters for normalized heartbeats (normEcg(k)). Thedirection parameter is determined by the following formula:direct(k)=arc Tan[(yMax(k)−yMin(k))/(xMax(k)−xMin(k))],

where:

arc Tan[ . . . ]—arctangent function;

{xMax(k),yMax(k)}—coordinates of maximum of the normalized heart beatfor k-th channel;

{xMin(k),yMin(k)}—coordinates of minimum of the normalized heart beatfor k-th channel.

The next step is computing the averaged values of the found parameters(avDirect(i), avWidth(i)) for given segment(i).

Until the learning buffer reaches the required number of points, eachpoint is saved and clustering is performed on the points in the buffer.FIG. 8 shows the dual parameter clustering, where the element (point) ofgroups is described by two parameters ({avDirect(i), avWidth(i)}). Anyknown method such as K-mean may be used as the clustering method. Afterclustering, the method saves two separated groups (A-cluster &V-cluster) for later use. Once the learning buffer is full, the methodtests a similarity of each incoming point to the clusters. The testanswer is reported. The method makes refinement operations for theclusters such as outlier deleting, a cluster center correcting, etc.

The steps for the method shown in FIG. 9 are as follows. In step 901,begin the current activity segment. Determine whetherk<=quantityOflCrefthn. If k<=quantityOflCrefChn (901=YES), then, in step902, calculate normEcg(k) to normalize current beat in k-th channel,that is: normEcg(k)=Ecg(k)/Max[Abs[Ecg(k))].

In step 903, calculate direction and width in k-th channel and continueprocessing at step 901.

If k>quantityOflCrefChn (901=NO), then in step 904, calculateavDirect(i), avWidth(i) as averaged direction and width for currentactivity (i).

In step 905, determine whether or not I>=nLearnBuf. If I>=nLearnBuf(905=YES), then, in step 906, test similarity of current point(avDirect(i), avWidth(i)) to one of the clusters. In step 907, correctcluster buffers and continue processing at step 909.

If I<nLearnBuf (905=NO), in step 908, save the current point(avDirect(i), avWidth(i)) in learn buffer and clustering. In step 909,save cluster buffers. In step 910, increment the A-cluster and V-clusterby setting i=i+1.

In implementing the morphological A-V discrimination method, theprocessor 14 is configured to discriminate IC-ECG oscillating signalsegments as A-activity or V-activity such that an IC-ECG oscillatingsignal segment is designated as V-activity upon a condition that acombination of a slope and a width of a primary oscillation is less thana predetermined threshold and to otherwise designate the IC-ECGoscillating signal segment as A-activity.

FIGS. 10-12A-D illustrate a modification to the system for thearrhythmia case of atrial flutter (AFL). In AFL, A-activities oftenoccur around the same time as the BS annotations. As a result, theclassification can be incorrect, that is, A-activity can bemisclassified as V-activity. In this embodiment, an AFL mode method ispresented, as shown in FIG. 10. The method of FIG. 10 is combined withthe method discussed in FIG. 3B, above. FIG. 10 contains two sub-blocks.The first sub-block is designed for searching A-activity under AtrialFlutter (AFL) which is explained further in connection with FIG. 11.

AFL is an abnormal heart rhythm that can cause the top chambers (atria)and the bottom chambers (ventricles) to beat at different speeds. It isone of the most common cardiac arrhythmias. It is important to note thatA- and V-activities may overlap one another under AFL, so this situationmay be processed by special methods. Firstly, the AFL mode conditionsare checked; if their combination is true, AFL sub-block starts itsaction, otherwise the second sub-block starts the discriminationprocess. For the second sub-block, two alternative embodiments arepresented: based on BS annotations (shown in FIG. 6) and based onmorphological features of IC ECG (shown in FIGS. 7-9). The secondembodiment is useful in a case in which BS ECGs cannot be used.

The steps in FIG. 10 are as follows. In step 1001, the block of the AFLmode checks flutter conditions and the check results in a Boolean flag(boolFlgCL). Step 1002 determines whether or not boolFlgCL is true. IfboolFlgCL is true (1002=YES), in step 1003, the atrial annotations aresearched. In particular, in step 1003, the classifier initiates theblock of the flutter mode (as discussed in FIG. 11, below) and then theblock of the blanking window classification method (as discussed in FIG.3, above).

If boolFlgCL is not true (1002=NO), the block of the blanking windowmethod is activated, 1004, which is equivalent to the algorithmdisclosed in FIG. 6, as discussed above.

The main conditions to enter AFL (flutter mode) may be: fast rhythm(CL,450 ms); high stability of the CL (relative standard deviationapproximately 5-7%) and the ratio of annotations quantity for IC to BSis greater than 1. In order to calculate these characteristics, themethod uses the updating buffers of the last classified A-activity ICannotations (bufferAnnoA) and the last estimations of all annotationcandidates before classification (bufferAnnoAV).

FIG. 11 shows an AFL mode method for block 1003 of FIG. 10. This methoduses and updates bufferAnnoA, bufferAnnoAV global buffers and temporalbuffer of the IC channel annotations (bufferAnnoIC). The method startsfrom calculation of an approximate group annotation (approxGrpAnno)which is the weighted average of all found channel annotations:

where:

${{approxGrpAnno} = \frac{\sum\limits_{k}{{A(k)}*{{annChnIC}(k)}}}{\sum\limits_{k}{A(k)}}},$

where:

annChnIC(k)—IC annotation in k-th channel;

A(k)—Ecg maximal absolute value of k-th channel.

Next the block performs the calculations, condition validity and IC_Aestimation in a loop. A quantity of the loop steps depends on theelement number of approxGrpAnno vector. The loop step starts fromcalculating the CL quantile (quantileCLforAV) for current state ofbufferAnnoAV. Then the method checks the following condition:approxGrpAnno(i)−bufferAnnoA(−1)>factorThrCL*quantileCLforAV,

where:

approxGrpAnno(i)—value of approxGrpAnno in i-th loop step;

bufAnnoA(−1)—the last classified IC_A annotation;

factorThrCL—some pre-set factor for the lower bound of CL.

If the condition is true, we can estimate IC_A annotation, otherwise theloop starts a next step. After a successful IC_A annotation estimation,its value is saved in bufAnnoA buffer and first buffer element isdeleted. The same update is carried out for bufLastAnnoAV buffer. Theused element of bufferAnnoIC buffer is deleted.

The steps of the method shown in FIG. 11 are as follows. In step 1101,calculate approximate IC group annotations, e.g., weighted average bymax amplitude. In step 1102, determine whether or notI<=Length[approxGrpAnno]. If I<=Length[approxGrpAnno (1102=YES), then instep 1103 calculate quantile of CL for AFL mode.

In step 1104, determine whether or notAbs[approxGrpAnno(i)-lastICA]>factorThrCL*quantileCLforAV. IfAbs[approxGrpAnno(i)-lastICA]>factorThrCL*quantileCLforAV (1104=YES),then in step 1105, calculate current ICA annotation. In step 1106,update buffers of IC annotations (e.g., bufferAnnoIC, bufferAnnoA andBufLastAnnoAV).

If Abs[approxGrpAnno(i)-lastICA]<=factorThrCL*quantileCLforAV (1104=NO),then go to step 1102.

If I>Length[approxGrpAnno] (1102=NO), then processing is complete.

A results comparison of classification methods with AFL mode module 1202and without AFL mode module 1201 for atrial flutter case is presented inFIGS. 12D and 12C, respectively. As shown, a classifier without the AFLmode module misses each second A-activity. For general implementation ofthe AFL mode, the processor 14 is configured to designate the IC-ECGoscillating signal segments as A-activity upon the condition that atrialflutter is detected for the sensed heartbeat and a blanking windowexists between successive IC-ECG oscillating signal segments for thesensed heartbeat.

The present method may have two modes: Manual mode and Automatic(“auto”) mode. In either mode, one can provide a beat to track and/orcan set thresholds around time to filter out a beat.

In auto mode, one can look at all beats acquired in statistical mannerand cluster the beats by time sequence. The cluster may be presented tothe physician as a filtered collection of data; the extracted cluster ofbeats can be used to generate the map. In the auto mode, there is noneed to provide a template; instead, the present method generates atemplate from the acquired beats.

In manual mode, the user may select data of a specific heartbeat for thebasis of a time sequence template. Then, the method takes that timesequence template and uses it to match all the heartbeats in theacquired data. Only heartbeats that are matched are used in the LAT map.

It will be appreciated by persons skilled in the art that the presentteachings are not limited to what has been particularly shown anddescribed hereinabove. Rather, the scope of the present teachingsinclude both combinations and sub-combinations of the various featuresdescribed hereinabove, as well as variations and modifications thereofthat are not in the prior art, which would occur to persons skilled inthe art upon reading the foregoing description.

The methods provided include implementation in a general purposecomputer, a processor, or a processor core. Suitable processors include,by way of example, a general purpose processor, a special purposeprocessor, a conventional processor, a digital signal processor (DSP), aplurality of microprocessors, one or more microprocessors in associationwith a DSP core, a controller, a microcontroller, Application SpecificIntegrated Circuits (ASICs), Field Programmable Gate Arrays (FPGAs)circuits, any other type of integrated circuit (IC), and/or a statemachine. Such processors can be manufactured by configuring amanufacturing process using the results of processed hardwaredescription language (HDL) instructions and other intermediary dataincluding netlists (such instructions capable of being stored on acomputer readable media). The results of such processing can be maskworks that are then used in a semiconductor manufacturing process tomanufacture a processor which implements methods described herein.

The methods or flow charts provided herein can be implemented in acomputer program, software, or firmware incorporated in a non-transitorycomputer-readable storage medium for execution by a general purposecomputer or a processor. Examples of non-transitory computer-readablestorage mediums include a ROM, a random access memory (RAM), a register,cache memory, semiconductor memory devices, magnetic media such asinternal hard disks and removable disks, magneto-optical media, andoptical media such as CD-ROM disks, and digital versatile disks (DVDs).

What is claimed is:
 1. A medical apparatus configured to classifyheartbeats based on intracardiac and body surface electrocardiogram(ECG) signals comprising: an intracardiac catheter configured to obtainmultiple channels of intracardiac ECG (IC-ECG) signals via respectivemultiple electrodes when disposed within a heart within a body of asubject; a body surface ECG sensing device configured to obtain multiplechannels of body surface ECG (BS-ECG) signals via multiple electrodeswhen disposed on the body of the subject; a processor configured toreceive and process respective ECG signals from the intracardiaccatheter and body surface ECG sensing device; the processor configuredto define a BS annotation of BS-ECG oscillating signal segmentsreflective of a sensed heartbeat of the subject, the BS annotationincluding a BS annotation time value relative to the sensed heartbeat;the processor configured to perform a morphology comparison of theBS-ECG oscillating signal segments reflective of the sensed heartbeatwith one or more morphology templates, where each morphology template isassociated with a heartbeat classification, and classify the sensedheartbeat as corresponding to the associated heartbeat classification ofa template for which the morphology comparison reflects a predetermineddegree of morphology similarity; the processor configured to define ICannotations of IC-ECG oscillating signal segments for each channel whichreflect atrial-activity (A-activity) or ventricular activity(V-activity) of the sensed heartbeat of the subject, each IC annotationincluding an IC annotation time value relative to the sensed heartbeat;the processor configured to discriminate IC-ECG oscillating signalsegments as A-activity or V-activity and designate IC annotations asIC-A annotations or IC-V annotations, respectively; the processorconfigured to perform an Atrial time sequence comparison of IC-Aannotations reflective of the sensed heartbeat with one or more Atrialtime sequence templates, where each Atrial time sequence template isassociated with an A-activity classification, and classify the sensedheartbeat as corresponding to the associated A-activity classificationof a template for which the Atrial time sequence comparison reflects apredetermined degree of Atrial time sequence similarity; the processorconfigured to perform a Ventricular time sequence comparison of IC-Vannotations reflective of the sensed heartbeat with one or moreVentricular time sequence templates, where each Ventricular timesequence template is associated with a V-activity classification, andclassify the sensed heartbeat as corresponding to the associatedV-activity classification of a template for which the Ventricular timesequence comparison reflects a predetermined degree of Ventricular timesequence similarity; and an output device coupled to the processorconfigured to selectively output classifications of sensed heartbeatsresulting from morphology and time sequence comparisons; wherein theprocessor s configured to create a new morphology, Atrial time sequenceor Ventricular time sequence template based upon a condition that aheartbeat classification is not made based on a respective comparison toexisting morphology, Atrial time sequence or Ventricular time sequencetemplates.
 2. A medical apparatus configured to classify heartbeatsbased on intracardiac and body surface electrocardiogram (ECG) signalscomprising: an intracardiac catheter configured to obtain multiplechannels of intracardiac ECG (IC-ECG) signals via respective multipleelectrodes when disposed within a heart within a body of a subject; abody surface ECG sensing device configured to obtain multiple channelsof body surface ECG (BS-ECG) signals via multiple electrodes whendisposed on the body of the subject; a processor configured to receiveand process respective ECG signals from the intracardiac catheter andbody surface ECG sensing device; the processor configured to define a BSannotation of BS-ECG oscillating signal segments reflective of a sensedheartbeat of the subject, the BS annotation including a BS annotationtime value relative to the sensed heartbeat; the processor configured toperform a morphology comparison of the BS-ECG oscillating signalsegments reflective of the sensed heartbeat with one or more morphologytemplates, where each morphology template is associated with a heartbeatclassification, and classify the sensed heartbeat as corresponding tothe associated heartbeat classification of a template for which themorphology comparison reflects a predetermined degree of morphologysimilarity; the processor configured to define IC annotations of IC-ECGoscillating signal segments for each channel which reflectatrial-activity (A-activity) or ventricular activity (V-activity) of thesensed heartbeat of the subject, each IC annotation including an ICannotation time value relative to the sensed heartbeat; the processorconfigured to discriminate IC-ECG oscillating signal segments asA-activity or V-activity and designate IC annotations as IC-Aannotations or IC-V annotations, respectively; the processor configuredto perform an Atrial time sequence comparison of IC-A annotationsreflective of the sensed heartbeat with one or more Atrial time sequencetemplates, where each Atrial time sequence template is associated withan A-activity classification, and classify the sensed heartbeat ascorresponding to the associated A-activity classification of a templatefor which the Atrial time sequence comparison reflects a predetermineddegree of Atrial time sequence similarity; the processor configured toperform a Ventricular time sequence comparison of IC-V annotationsreflective of the sensed heartbeat with one or more Ventricular timesequence templates, where each Ventricular time sequence template isassociated with a V-activity classification, and classify the sensedheartbeat as corresponding to the associated V-activity classificationof a template for which the Ventricular time sequence comparisonreflects a predetermined degree of Ventricular time sequence similarity;and an output device coupled to the processor configured to selectivelyoutput classifications of sensed heartbeats resulting from morphologyand time sequence comparisons; wherein the processor is configured todiscriminate IC-ECG signal oscillating signal segments as A-activity orV-activity such that an IC-ECG oscillating signal segment is designatedas V-activity upon a condition that the IC annotation time valuerelative to the sensed heartbeat is within a range of time valuesstarting a predetermined amount before the BS annotation time valuerelative to the sensed heartbeat and ending a predetermined amount afterthe BS annotation time value relative to the sensed heartbeat and tootherwise designate the IC-ECG oscillating signal segment as A-activity.3. The apparatus of claim 2 wherein the processor is configured todesignate the IC-ECG oscillating signal segment as V-activity upon thecondition that the IC annotation time value relative to the sensedheartbeat is within a range of time values starting at no less than 20milliseconds before the BS annotation time value relative to the sensedheartbeat and ending no more than 80 milliseconds after the BSannotation time value relative to the sensed heartbeat.
 4. A medicalapparatus configured to classify heartbeats based on intracardiac andbody surface electrocardiogram (ECG) signals comprising: an intracardiaccatheter configured to obtain multiple channels of intracardiac ECG(IC-ECG) signals via respective multiple electrodes when disposed withina heart within a body of a subject; a body surface ECG sensing deviceconfigured to obtain multiple channels of body surface ECG (BS-ECG)signals via multiple electrodes when disposed on the body of thesubject; a processor configured to receive and process respective ECGsignals from the intracardiac catheter and body surface ECG sensingdevice; the processor configured to define a BS annotation of BS-ECGoscillating signal segments reflective of a sensed heartbeat of thesubject, the BS annotation including a BS annotation time value relativeto the sensed heartbeat; the processor configured to perform amorphology comparison of the BS-ECG oscillating signal segmentsreflective of the sensed heartbeat with one or more morphologytemplates, where each morphology template is associated with a heartbeatclassification, and classify the sensed heartbeat as corresponding tothe associated heartbeat classification of a template for which themorphology comparison reflects a predetermined degree of morphologysimilarity; the processor configured to define IC annotations of IC-ECGoscillating signal segments for each channel which reflectatrial-activity (A-activity) or ventricular activity (V-activity) of thesensed heartbeat of the subject, each IC annotation including an ICannotation time value relative to the sensed heartbeat; the processorconfigured to discriminate IC-ECG oscillating signal segments asA-activity or V-activity and designate IC annotations as IC-Aannotations or IC-V annotations, respectively; the processor configuredto perform an Atrial time sequence comparison of IC-A annotationsreflective of the sensed heartbeat with one or more Atrial time sequencetemplates, where each Atrial time sequence template is associated withan A-activity classification, and classify the sensed heartbeat ascorresponding to the associated A-activity classification of a templatefor which the Atrial time sequence comparison reflects a predetermineddegree of Atrial time sequence similarity; the processor configured toperform a Ventricular time sequence comparison of IC-V annotationsreflective of the sensed heartbeat with one or more Ventricular timesequence templates, where each Ventricular time sequence template isassociated with a V-activity classification, and classify the sensedheartbeat as corresponding to the associated V-activity classificationof a template for which the Ventricular time sequence comparisonreflects a predetermined degree of Ventricular time sequence similarity;and an output device coupled to the processor configured to selectivelyoutput classifications of sensed heartbeats resulting from morphologyand time sequence comparisons; wherein the processor s configured todiscriminate IC-ECG oscillating signal segments as A-activity orV-activity such that an IC-ECG oscillating signal segment is designatedas A-activity or V-activity based upon morphology characteristics of theIC-ECG oscillating signal segment.
 5. The apparatus of claim 4 whereinthe processor is configured to discriminate IC-ECG oscillating signalsegments as A-activity or V-activity such that an IC-ECG oscillatingsignal segment is designated as V-activity upon a condition that acombination of a slope and a width of a primary oscillation is less thana predetermined threshold and to otherwise designate the IC-ECGoscillating signal segment as A-activity.
 6. A medical apparatusconfigured to classify heartbeats based on intracardiac and body surfaceelectrocardiogram (ECG) signals comprising: an intracardiac catheterconfigured to obtain multiple channels of intracardiac ECG (IC-ECG)signals via respective multiple electrodes when disposed within a heartwithin a body of a subject; a body surface ECG sensing device configuredto obtain multiple channels of body surface ECG (BS-ECG) signals viamultiple electrodes when disposed on the body of the subject; aprocessor configured to receive and process respective ECG signals fromthe intracardiac catheter and body surface ECG sensing device; theprocessor configured to define a BS annotation of BS-ECG oscillatingsignal segments reflective of a sensed heartbeat of the subject, the BSannotation including a BS annotation time value relative to the sensedheartbeat; the processor configured to perform a morphology comparisonof the BS-ECG oscillating signal segments reflective of the sensedheartbeat with one or more morphology templates, where each morphologytemplate is associated with a heartbeat classification, and classify thesensed heartbeat as corresponding to the associated heartbeatclassification of a template for which the morphology comparisonreflects a predetermined degree of morphology similarity; the processorconfigured to define IC annotations of IC-ECG oscillating signalsegments for each channel which reflect atrial-activity (A-activity) orventricular activity (V-activity) of the sensed heartbeat of thesubject, each IC annotation including an IC annotation time valuerelative to the sensed heartbeat; the processor configured todiscriminate IC-ECG oscillating signal segments as A-activity orV-activity and designate IC annotations as IC-A annotations or IC-Vannotations, respectively; the processor configured to perform an Atrialtime sequence comparison of IC-A annotations reflective of the sensedheartbeat with one or more Atrial time sequence templates, where eachAtrial time sequence template is associated with an A-activityclassification, and classify the sensed heartbeat as corresponding tothe associated A-activity classification of a template for which theAtrial time sequence comparison reflects a predetermined degree ofAtrial time sequence similarity; the processor configured to perform aVentricular time sequence comparison of IC-V annotations reflective ofthe sensed heartbeat with one or more Ventricular time sequencetemplates, where each Ventricular time sequence template is associatedwith a V-activity classification, and classify the sensed heartbeat ascorresponding to the associated V-activity classification of a templatefor which the Ventricular time sequence comparison reflects apredetermined degree of Ventricular time sequence similarity; and anoutput device coupled to the processor configured to selectively outputclassifications of sensed heartbeats resulting from morphology and timesequence comparisons; wherein the processor is configured to designatethe IC-ECG oscillating signal segments as A-activity upon the conditionthat atrial nutter is detected for the sensed heartbeat and a blankingwindow exists between successive IC-ECG oscillating signal segments forthe sensed heartbeat.
 7. A medical apparatus configured to classifyheartbeats based on intracardiac and body surface electrocardiogram(ECG) signals comprising: an intracardiac catheter configured to obtainmultiple channels of intracardiac ECG (IC-ECG) signals via respectivemultiple electrodes when disposed within a heart within a body of asubject; a body surface ECG sensing device configured to obtain multiplechannels of body surface ECG (BS-ECG) signals via multiple electrodeswhen disposed on the body of the subject; a processor configured toreceive and process respective ECG signals from the intracardiaccatheter and body surface ECG sensing device; the processor configuredto define a BS annotation of BS-ECG oscillating signal segmentsreflective of a sensed heartbeat of the subject, the BS annotationincluding a BS annotation time value relative to the sensed heartbeat;the processor configured to perform a morphology comparison of theBS-ECG oscillating signal segments reflective of the sensed heartbeatwith one or more morphology templates, where each morphology template isassociated with a heartbeat classification, and classify the sensedheartbeat as corresponding to the associated heartbeat classification ofa template for which the morphology comparison reflects a predetermineddegree of morphology similarity; the processor configured to define ICannotations of IC-ECG oscillating signal segments for each channel whichreflect atrial-activity (A-activity) or ventricular activity(V-activity) of the sensed heartbeat of the subject, each IC annotationincluding an IC annotation time value relative to the sensed heartbeat;the processor configured to discriminate IC-ECG oscillating signalsegments as A-activity or V-activity and designate IC annotations asIC-A annotations or IC-V annotations, respectively; the processorconfigured to perform an Atrial time sequence comparison of IC-Aannotations reflective of the sensed heartbeat with one or more Atrialtime sequence templates, where each Atrial time sequence template isassociated with an A-activity classification, and classify the sensedheartbeat as corresponding to the associated A-activity classificationof a template for which the Atrial time sequence comparison reflects apredetermined degree of Atrial time sequence similarity; the processorconfigured to perform a Ventricular time sequence comparison of IC-Vannotations reflective of the sensed heartbeat with one or moreVentricular time sequence templates, where each Ventricular timesequence template is associated with a V-activity classification, andclassify the sensed heartbeat as corresponding to the associatedV-activity classification of a template for which the Ventricular timesequence comparison reflects a predetermined degree of Ventricular timesequence similarity; and an output device coupled to the processorconfigured to selectively output classifications of sensed heartbeatsresulting from morphology and time sequence comparisons; wherein: theprocessor is configured to perform an Atrial time sequence comparison ofIC-A annotations reflective of the sensed heartbeat with an Atrial timesequence template by: calculating a time value difference between the ICannotation time value of the IC-A annotation for each channel of thesensed heartbeat and a respective template channel annotation timevalue, and determining that the predetermined degree of Atrial timesequence similarity occurs when the combination of the absolute value ofthe combined differences is no greater than a selected A-time threshold;and the processor is configured to perform a Ventricular time sequencecomparison of IC-V annotations reflective of the sensed heartbeat with aVentricular time sequence template by: calculating a time valuedifference between the IC annotation time value of the IC-V annotationfor each channel of the sensed heartbeat and a respective templatechannel annotation time value, and determining that the predetermineddegree of Ventricular time sequence similarity occurs when thecombination of the absolute value of the combined differences is nogreater than a selected V-time threshold.
 8. A medical apparatusconfigured to classify heartbeats based on intracardiac and body surfaceelectrocardiogram (ECG) signals comprising: an intracardiac catheterconfigured to obtain multiple channels of intracardiac ECG (IC-ECG)signals via respective multiple electrodes when disposed within a heartwithin a body of a subject; a body surface ECG sensing device configuredto obtain multiple channels of body surface ECG (BS-ECG) signals viamultiple electrodes when disposed on the body of the subject; aprocessor configured to receive and process respective ECG signals fromthe intracardiac catheter and body surface ECG sensing device; theprocessor configured to define a BS annotation of BS-ECG oscillatingsignal segments reflective of a sensed heartbeat of the subject, the BSannotation including a BS annotation time value relative to the sensedheartbeat; the processor configured to perform a morphology comparisonof the BS-ECG oscillating signal segments reflective of the sensedheartbeat with one or more morphology templates, where each morphologytemplate is associated with a heartbeat classification, and classify thesensed heartbeat as corresponding to the associated heartbeatclassification of a template for which the morphology comparisonreflects a predetermined degree of morphology similarity; the processorconfigured to define IC annotations of IC-ECG oscillating signalsegments for each channel which reflect atrial-activity (A-activity) orventricular activity (V-activity) of the sensed heartbeat of thesubject, each IC annotation including an IC annotation time valuerelative to the sensed heartbeat; the processor configured todiscriminate IC-ECG oscillating signal segments as A-activity orV-activity and designate IC annotations as IC-A annotations or IC-Vannotations, respectively; the processor configured to perform an Atrialtime sequence comparison of IC-A annotations reflective of the sensedheartbeat with one or more Atrial time sequence templates, where eachAtrial time sequence template is associated with an A-activityclassification, and classify the sensed heartbeat as corresponding tothe associated A-activity classification of a template for which theAtrial time sequence comparison reflects a predetermined degree ofAtrial time sequence similarity; the processor configured to perform aVentricular time sequence comparison of IC-V annotations reflective ofthe sensed heartbeat with one or more Ventricular time sequencetemplates, where each Ventricular time sequence template is associatedwith a V-activity classification, and classify the sensed heartbeat ascorresponding to the associated V-activity classification of a templatefor which the Ventricular time sequence comparison reflects apredetermined degree of Ventricular time sequence similarity; and anoutput device coupled to the processor configured to selectively outputclassifications of sensed heartbeats resulting from morphology and timesequence comparisons; wherein the output device comprises a monitorconfigured to selectively display ECG signal and heartbeatclassification data of sensed heartbeats.
 9. A method for classifyingheartbeats based on intracardiac and body surface electrocardiogram(ECG) signals comprising: obtaining multiple channels of intracardiacECG (IC-ECG) signals via respective multiple electrodes from within aheart within a body of a subject; obtaining multiple channels of bodysurface ECG (BS-ECG) signals from the body of the subject; processingthe IC-ECG and BS-ECG signals; defining a BS annotation of BS-ECGoscillating signal segments reflective of a sensed heartbeat, the BSannotation including a BS annotation time value relative to the sensedheartbeat; performing a morphology comparison of the BS-ECG oscillatingsignal segments reflective of the sensed heartbeat with one or moremorphology templates, where each morphology template is associated witha heartbeat classification, and classifying the sensed heartbeat ascorresponding to the associated heartbeat classification of a templatefor which the morphology comparison reflects a predetermined degree ofmorphology similarity; defining IC annotations of IC-ECG oscillatingsignal segments for each channel which reflect atrial-activity(A-activity) or ventricular activity (V-activity) of the sensedheartbeat, each IC annotation including an IC annotation time valuerelative to the sensed heartbeat; discriminating IC-ECG oscillatingsignal segments as A-activity or V-activity and designating ICannotations as IC-A annotations or IC-V annotations, respectively;performing at least one of: an Atrial time sequence comparison of IC-Aannotations reflective of the sensed heartbeat with one or more Atrialtime sequence templates, where each Atrial time sequence template isassociated with an A-activity classification, and classifying the sensedheartbeat as corresponding to the associated A-activity classificationof a template for which the Atrial time sequence comparison reflects apredetermined degree of Atrial time sequence similarity; and aVentricular time sequence comparison of IC-V annotations reflective ofthe sensed heartbeat with one or more Ventricular time sequencetemplates, where each Ventricular time sequence template is associatedwith a V-activity classification, and classifying the sensed heartbeatas corresponding to the associated V-activity classification of atemplate for which the Ventricular time sequence comparison reflects apredetermined degree of Ventricular time sequence similarity;selectively outputting classifications of sensed heartbeats resultingfrom morphology and time sequence comparisons; and creating a newmorphology, Atrial time sequence or Ventricular time sequence templatebased upon a condition that a heartbeat classification is not made basedon a respective comparison to existing morphology, Atrial time sequenceor Ventricular time sequence templates.
 10. A method for classifyingheartbeats based on intracardiac and body surface electrocardiogram(ECG) signals comprising: obtaining multiple channels of intracardiacECG (IC-ECG) signals via respective multiple electrodes from within aheart within a body of a subject; obtaining multiple channels of bodysurface ECG (BS-ECG) signals from the body of the subject; processingthe IC-ECG and BS-ECG signals; defining a BS annotation of BS-ECGoscillating signal segments reflective of a sensed heartbeat, the BSannotation including a BS annotation time value relative to the sensedheartbeat; performing a morphology comparison of the BS-ECG oscillatingsignal segments reflective of the sensed heartbeat with one or moremorphology templates, where each morphology template is associated witha heartbeat classification, and classifying the sensed heartbeat ascorresponding to the associated heartbeat classification of a templatefor which the morphology comparison reflects a predetermined degree ofmorphology similarity; defining IC annotations of IC-ECG oscillatingsignal segments for each channel which reflect atrial-activity(A-activity) or ventricular activity (V-activity) of the sensedheartbeat, each IC annotation including an IC annotation time valuerelative to the sensed heartbeat; discriminating IC-ECG oscillatingsignal segments as A-activity or V-activity and designating ICannotations as IC-A annotations or IC-V annotations, respectively;performing at least one of: an Atrial time sequence comparison of IC-Aannotations reflective of the sensed heartbeat with one or more Atrialtime sequence templates, where each Atrial time sequence template isassociated with an A-activity classification, and classifying the sensedheartbeat as corresponding to the associated A-activity classificationof a template for which the Atrial time sequence comparison reflects apredetermined degree of Atrial time sequence similarity; and aVentricular time sequence comparison of IC-V annotations reflective ofthe sensed heartbeat with one or more Ventricular time sequencetemplates, where each Ventricular time sequence template is associatedwith a V-activity classification, and classifying the sensed heartbeatas corresponding to the associated V-activity classification of atemplate for which the Ventricular time sequence comparison reflects apredetermined degree of Ventricular time sequence similarity; andselectively outputting classifications of sensed heartbeats resultingfrom morphology and time sequence comparisons; wherein thediscriminating IC-ECG oscillating signal segments as A-activity orV-activity is performed such that an IC-ECG oscillating signal segmentis designated as V-activity upon a condition that the IC annotation timevalue relative to the sensed heartbeat is within a range of time valuesstarting a predetermined amount before the BS annotation time valuerelative to the sensed heartbeat and ending a predetermined amount afterthe BS annotation time value relative to the sensed heartbeat andotherwise the IC-ECG oscillating signal segment is designated asA-activity.
 11. The method of claim 10 wherein the IC-ECG oscillatingsignal segment is designated as V-activity upon the condition that theIC annotation time value relative to the sensed heartbeat is within arange of time values starting at no less than 20 milliseconds before theBS annotation time value relative to the sensed heartbeat and ending nomore than 80 milliseconds after the BS annotation time value relative tothe sensed heartbeat.
 12. A method for classifying heartbeats based onintracardiac and body surface electrocardiogram (ECG) signalscomprising: obtaining multiple channels of intracardiac ECG (IC-ECG)signals via respective multiple electrodes from within a heart within abody of a subject; obtaining multiple channels of body surface ECG(BS-ECG) signals from the body of the subject; processing the IC-ECG andBS-ECG signals; defining a BS annotation of BS-ECG oscillating signalsegments reflective of a sensed heartbeat, the BS annotation including aBS annotation time value relative to the sensed heartbeat; performing amorphology comparison of the BS-ECG oscillating signal segmentsreflective of the sensed heartbeat with one or more morphologytemplates, where each morphology template is associated with a heartbeatclassification, and classifying the sensed heartbeat as corresponding tothe associated heartbeat classification of a template for which themorphology comparison reflects a predetermined degree of morphologysimilarity; defining IC annotations of IC-ECG oscillating signalsegments for each channel which reflect atrial-activity (A-activity) orventricular activity (V-activity) of the sensed heartbeat, each ICannotation including an IC annotation time value relative to the sensedheartbeat; discriminating IC-ECG oscillating signal segments asA-activity or V-activity and designating IC annotations as IC-Aannotations or IC-V annotations, respectively; performing at least oneof: an Atrial time sequence comparison of IC-A annotations reflective ofthe sensed heartbeat with one or more Atrial time sequence templates,where each Atrial time sequence template is associated with anA-activity classification, and classifying the sensed heartbeat ascorresponding to the associated A-activity classification of a templatefor which the Atrial time sequence comparison reflects a predetermineddegree of Atrial time sequence similarity; and a Ventricular timesequence comparison of IC-V annotations reflective of the sensedheartbeat with one or more Ventricular time sequence templates, whereeach Ventricular time sequence template is associated with a V-activityclassification, and classifying the sensed heartbeat as corresponding tothe associated V-activity classification of a template for which theVentricular time sequence comparison reflects a predetermined degree ofVentricular time sequence similarity; and selectively outputtingclassifications of sensed heartbeats resulting from morphology and timesequence comparisons; wherein the discriminating IC-ECG oscillatingsignal segments as A-activity or V-activity is performed such that anIC-ECG oscillating signal segment is designated as A-activity orV-activity based upon morphology characteristics of the IC-ECGoscillating signal segment.
 13. The method of claim 12 wherein thediscriminating IC-ECG oscillating signal segments as A-activity orV-activity is performed such that an IC-ECG oscillating signal segmentis designated as V-activity upon a condition that a combination of aslope and a width of a primary oscillation is less than a predeterminedthreshold and otherwise the IC-ECG oscillating signal segment isdesignated as A-activity.
 14. A method for classifying heartbeats basedon intracardiac and body surface electrocardiogram (ECG) signalscomprising: obtaining multiple channels of intracardiac ECG (IC-ECG)signals via respective multiple electrodes from within a heart within abody of a subject; obtaining multiple channels of body surface ECG(BS-ECG) signals from the body of the subject; processing the IC-ECG andBS-ECG signals; defining a BS annotation of BS-ECG oscillating signalsegments reflective of a sensed heartbeat, the BS annotation including aBS annotation time value relative to the sensed heartbeat; performing amorphology comparison of the BS-ECG oscillating signal segmentsreflective of the sensed heartbeat with one or more morphologytemplates, where each morphology template is associated with a heartbeatclassification, and classifying the sensed heartbeat as corresponding tothe associated heartbeat classification of a template for which themorphology comparison reflects a predetermined degree of morphologysimilarity; defining IC annotations of IC-ECG oscillating signalsegments for each channel which reflect atrial-activity (A-activity) orventricular activity (V-activity) of the sensed heartbeat, each ICannotation including an IC annotation time value relative to the sensedheartbeat; discriminating IC-ECG oscillating signal segments asA-activity or V-activity and designating IC annotations as IC-Aannotations or IC-V annotations, respectively; performing at least oneof: an Atrial time sequence comparison of IC-A annotations reflective ofthe sensed heartbeat with one or more Atrial time sequence templates,where each Atrial time sequence template is associated with anA-activity classification, and classifying the sensed heartbeat ascorresponding to the associated A-activity classification of a templatefor which the Atrial time sequence comparison reflects a predetermineddegree of Atrial time sequence similarity; and a Ventricular timesequence comparison of IC-V annotations reflective of the sensedheartbeat with one or more Ventricular time sequence templates, whereeach Ventricular time sequence template is associated with a V-activityclassification, and classifying the sensed heartbeat as corresponding tothe associated V-activity classification of a template for which theVentricular time sequence comparison reflects a predetermined degree ofVentricular time sequence similarity; and selectively outputtingclassifications of sensed heartbeats resulting from morphology and timesequence comparisons; wherein the designating the IC-ECG oscillatingsignal segments as A-activity upon the condition that atrial flutter isdetected for the sensed heartbeat and a blanking window exists betweensuccessive IC-ECG oscillating signal segments for the sensed heartbeat.15. A method for classifying heartbeats based on intracardiac and bodysurface electrocardiogram (ECG) signals comprising: obtaining multiplechannels of intracardiac ECG (IC-ECG) signals via respective multipleelectrodes from within a heart within a body of a subject; obtainingmultiple channels of body surface ECG (BS-ECG) signals from the body ofthe subject; processing the IC-ECG and BS-ECG signals; defining a BSannotation of BS-ECG oscillating signal segments reflective of a sensedheartbeat, the BS annotation including a BS annotation time valuerelative to the sensed heartbeat; performing a morphology comparison ofthe BS-ECG oscillating signal segments reflective of the sensedheartbeat with one or more morphology templates, where each morphologytemplate is associated with a heartbeat classification, and classifyingthe sensed heartbeat as corresponding to the associated heartbeatclassification of a template for which the morphology comparisonreflects a predetermined degree of morphology similarity; defining ICannotations of IC-ECG oscillating signal segments for each channel whichreflect atrial-activity (A-activity) or ventricular activity(V-activity) of the sensed heartbeat, each IC annotation including an ICannotation time value relative to the sensed heartbeat; discriminatingIC-ECG oscillating signal segments as A-activity or V-activity anddesignating IC annotations as IC-A annotations or IC-V annotations,respectively; performing at least one of: an Atrial time sequencecomparison of IC-A annotations reflective of the sensed heartbeat withone or more Atrial time sequence templates, where each Atrial timesequence template is associated with an A-activity classification, andclassifying the sensed heartbeat as corresponding to the associatedA-activity classification of a template for which the Atrial timesequence comparison reflects a predetermined degree of Atrial timesequence similarity; and a Ventricular time sequence comparison of IC-Vannotations reflective of the sensed heartbeat with one or moreVentricular time sequence templates, where each Ventricular timesequence template is associated with a V-activity classification, andclassifying the sensed heartbeat as corresponding to the associatedV-activity classification of a template for which the Ventricular timesequence comparison reflects a predetermined degree of Ventricular timesequence similarity; and selectively outputting classifications ofsensed heartbeats resulting from morphology and time sequencecomparisons; wherein: a A-trial time sequence comparison of IC-Aannotations reflective of the sensed heartbeat with an Atrial timesequence template is performed by: calculating a time value differencebetween the IC annotation time value of the IC-A annotation for eachchannel of the sensed heartbeat and a respective template channelannotation time value, and determining that the predetermined degree ofAtrial time sequence similarity occurs when the combination of theabsolute value of the combined differences is no greater than a selectedA-time threshold; and Ventricular time sequence comparison of IC-Vannotations reflective of the sensed heartbeat with a Ventricular timesequence template is performed by: calculating a time value differencebetween the IC annotation time value of the IC-V annotation for eachchannel of the sensed heartbeat and a respective template channelannotation time value, and determining that the predetermined degree ofVentricular time sequence similarity occurs when the combination of theabsolute value of the combined differences is no greater than a selectedV-time threshold.
 16. A method for classifying heartbeats based onintracardiac and body surface electrocardiogram (ECG) signalscomprising: obtaining multiple channels of intracardiac ECG (IC-ECG)signals via respective multiple electrodes from within a heart within abody of a subject; obtaining multiple channels of body surface ECG(BS-ECG) signals from the body of the subject; processing the IC-ECG andBS-ECG signals; defining a BS annotation of BS-ECG oscillating signalsegments reflective of a sensed heartbeat, the BS annotation including aBS annotation time value relative to the sensed heartbeat; performing amorphology comparison of the BS-ECG oscillating signal segmentsreflective of the sensed heartbeat with one or more morphologytemplates, where each morphology template is associated with a heartbeatclassification, and classifying the sensed heartbeat as corresponding tothe associated heartbeat classification of a template for which themorphology comparison reflects a predetermined degree of morphologysimilarity; defining IC annotations of IC-ECG oscillating signalsegments for each channel which reflect atrial-activity (A-activity) orventricular activity (V-activity) of the sensed heartbeat, each ICannotation including an IC annotation time value relative to the sensedheartbeat; discriminating IC-ECG oscillating signal segments asA-activity or V-activity and designating IC annotations as IC-Aannotations or IC-V annotations, respectively; performing at least oneof: an Atrial time sequence comparison of IC-A annotations reflective ofthe sensed heartbeat with one or more Atrial time sequence templates,where each Atrial time sequence template is associated with anA-activity classification, and classifying the sensed heartbeat ascorresponding to the associated A-activity classification of a templatefor which the Atrial time sequence comparison reflects a predetermineddegree of Atrial time sequence similarity; and a Ventricular timesequence comparison of IC-V annotations reflective of the sensedheartbeat with one or more Ventricular time sequence templates, whereeach Ventricular time sequence template is associated with a V-activityclassification, and classifying the sensed heartbeat as corresponding tothe associated V-activity classification of a template for which theVentricular time sequence comparison reflects a predetermined degree ofVentricular time sequence similarity; selectively outputtingclassifications of sensed heartbeats resulting from morphology and timesequence comparisons; and selectively displaying ECG signal andheartbeat classification data of sensed heartbeats.
 17. A medicalapparatus configured to classify heartbeats based on intracardiac andbody surface electrocardiogram (ECG) signals comprising: a first inputconfigured to receive multiple channels of intracardiac ECG (IC-ECG)signals via respective multiple electrodes from within a heart within abody of a subject; a second input configured to receive multiplechannels of body surface ECG (BS-ECG) signals via multiple electrodesfrom on the body of the subject; a processor configured to processreceived IC-ECG and BS-ECG signals; the processor configured to define aBS annotation of BS-ECG oscillating signal segments reflective of asensed heartbeat of the subject, the BS annotation including a BSannotation time value relative to the sensed heartbeat; the processorconfigured to define IC annotations of IC-ECG oscillating signalsegments for each channel which reflect atrial-activity (A-activity) orventricular activity (V-activity) of the sensed heartbeat of thesubject, each IC annotation including an IC annotation time valuerelative to the sensed heartbeat; the processor configured todiscriminate IC-ECG oscillating signal segments as A-activity orV-activity and designate IC annotations as IC-A annotations or IC-Vannotations, respectively; the processor configured to perform an Atrialtime sequence comparison of IC-A annotations reflective of the sensedheartbeat with one or more Atrial time sequence templates, where eachAtrial time sequence template is associated with an A-activityclassification, and classify the sensed heartbeat as corresponding tothe associated A-activity classification of a template for which theAtrial time sequence comparison reflects a predetermined degree ofAtrial time sequence similarity; the processor configured to perform aVentricular time sequence comparison of IC-V annotations reflective ofthe sensed heartbeat with one or more Ventricular time sequencetemplates, where each Ventricular time sequence template is associatedwith a V-activity classification, and classify the sensed heartbeat ascorresponding to the associated V-activity classification of a templatefor which the Ventricular time sequence comparison reflects apredetermined degree of Ventricular time sequence similarity; and anoutput device coupled to the processor configured to selectively outputclassifications of sensed heartbeats resulting from morphology and timesequence comparisons; wherein the processor is configured to create anew Atrial time sequence or Ventricular time sequence template basedupon a condition that a heartbeat classification is not made based on arespective comparison to existing Atrial time sequence or Ventriculartime sequence templates.